"Health For All" in Croatia

Health Coverage

2009-06-08T06:02:00.000-07:00

To help you better understand the health care system in Croatia, here is some information on their public health insurance plan. Thanks to Mr. Josip Paunovic for the info during our lecture at the Makarska City Hall.

Health insurance in Croatia is provided through the government, with about 80% of the funding from taxes and 20% from the federal budget. This health plan covers 97% of the population (the other 3% is not covered due to reasons like working or living outside of Croatia). Private providers and insurance options are also available, but the system is mostly public. In the U.S., there is currently no national health insurance program to cover all citizens. The only public programs in the U.S. are Medicaid, Medicare, and the Children’s Health Insurance Program. (The pictures are from the Public Health Insurance Buildings in Osijek).

According to the Croatian Ministry of Health, in 2003 total spending on health was estimated at 8.9% of GDP, in 2004 at 9.7% of GDP and in 2005 at 8.7% of GDP. In the U.S. in 2005, national health expenditures totaled 16$ of GDP, with this number increasing every year.

There are three types of care: primary, through small clinics; secondary, through hospitals; and tertiary, through institutional hospitals, typically more advanced procedures. This plan covers dental, hospitalizations, vision, and care at primary and secondary health centers. Pharmaceuticals are also included, and those that are covered are listed in a national database. One half the cost of tertiary services are covered under this plan. Cosmetic surgeries are not covered.

Patients are required to pay for certain publicly provided health services through co-payments or to buy supplemental health insurance. Certain groups are exempt from paying co-pays, including: the unemployed, disabled, people under 18, students, the military, war veterans with disabilities, and people that voluntarily donate blood more than once.

The Croatian health insurance program also includes services such as prenatal and maternity care, school health services, and care for the elderly and subsidizes costs of health care in remote regions. The government pays for public health, environmental protection, and health education, and provides paid maternity leave. The Public Health students were surprised to learn about this during our presentation at the Psychodermatology clinic in Zagreb. The psychologist giving the presentation came in during her maternity leave and told us a little about maternity leave in Croatia. Every woman has a child in Croatia has the choice of maternity leave up to one year from the child’s birth, with an additional 45 days of leave. After the first three month’s of the mother’s leave, the father can opt to take paternity leave if the mother chooses to go back to work. In the U.S., women do not have the right to maternity leave, and maternity leave policies differ from company to company.

During our time in Croatia, we discovered many things we liked about the country’s policies, like paid maternity leave, free education through college, and free health insurance for those under 18.

Also, we would like to say thank you to our wonderful professors, all of our guest speakers, program planners, tour guides, and to Mr. and Mrs. Phillips for allowing so many students the opportunity to visit and learn about such a wonderful country!

- Elizabeth

Brac

2009-06-07T13:07:00.000-07:00

We visited the island of Brac for one night and I think it is safe to say we all wish we had more time at this particular hotel (The BlueSun)!! May 31st marked our last hike of the trip. We hiked to a Monastery in what seemed like the middle of nowhere. No, scratch that- it was in the dead center of nowhere. The only way to get to the Monastery is by foot- up, down, and around a canyon surrounding the Monastery. We learned that the the villages were built deep into canyons because pirates would come and plunder the villages if they were close to the sea. The "church" was built in 1757 and was considered to be the cultural, spiritual, and educational center of the island.

The school portion was designated for four basic grades of education for children. After this level of schooling, kids of the area went to other villages on the island for more education. The school in the Monastery was operative until 1962, with a class size of 15 students. Everyday the students would bring a log for the fire, that was used for heat and cooking.

While touring the Monastery, we saw various sizes of original weights in the hall that were used by the monks.

We also saw the original kitchen of the Monastery, which is over 400 years old. The kitchen was a central place of the monk's lives.

The monks utilized the land to their benefit by producing goods for bartering. There was never any money exchanged for goods, just a barter system of different goods from foods to wool to furniture. Wheat and corn were ground to produce flour; if a person ground all day, they could produce 10 kilos of flour. There were 3000 olive trees available to the Monastery and this would produce 60,000 gallons of olive oil per year. We also saw a schematic of a beehive layout of the island. Three tons of honey were produced each year from the 237 beehives.

Outside in the courtyard of the Monastery, we learned of the bathroom mechanisms and burial methods for the Monastery. The bathroom was a pretty ingenious idea: there was what was like an outhouse to the side of the courtyard that utilized gravity for flushing. There are no pipes and no running water and the waste is naturally pulled down and away from the "bathroom".

The ancient burial processes for this island are much different from what we think of as burial processes. The dead were buried in a vertical position to make room for others in such a small and confined place. The bodies were wrapped in sheets, then placed in the ground. Once the bodies deteriorated, the bones would fall together in a pile and allow for more room in the burial pit. We learned that where we were standing former priests and residents were buried, totaling about 70 people buried in the courtyard.

Water is a major issue on an island. We learned that the monks would use cisterns to collect rain water and store it in jugs and pots for later use. The island of Brac is used to having many, many sunny days in the year, so rain was very precious. The water to the Monastery and the rest of the island now comes from pipes from the mainland.

There are five things to consider about water: quality (free of sediments, algae, parasites, and clean); cost (has to be affordable); proximity (must be within 1km of person); quantity (minimum amount needed for hygiene and cooking/drinking; 5L/person/day); and reliability (water must be available and there when one needs it). Water should be considered a basic human right, because an individual can only live without water for about a week. Water that is contaminated must be boiled to kill anything harmful (this is one of the reasons the students had to bring logs to school, to ensure a way to boil the water to clean it for drinking and cooking). Storage of the water is a part of proximity and reliability. The mechanisms used to store the water must not contain any cracks and must be easily transported. Storage of the water must also be close enough for the people to access if they are going to cook or clean. We learned that people who have reliable water sources have improved health.

We were also informed about trash being an important issue to consider on an island. There is already limited space on the island, so the trash produced by humans must either be incinerated or transported to a landfill, as to not waste space of the island. We learned that trash from Brac was picked up by barges on a regular basis and transported to a landfill on the mainland.

Mental health is the last issue we learned about that is important to island life. Recent data shows that Croats living on the islands scored higher in better physical conditions compared to those not living on an island. These people did score as having feelings of isolation, but it should be noted that they want an isolated life. This is the reason why they moved away to the island. They feel more vital and not restrained as they do on the mainland. Generally those who are sick or have underlying health problems do not stay on the island because of the limited access to health care. Island people are more likely to endure pain than their non island counterparts. There was also a significant decrease in gastric/pancreatic cancers of the Croatian island people compared to non-islanders.

This last hike was by far one of the hardest, but really interesting to participate in.
-Rachel

Last night in Croatia

2009-06-02T11:35:00.001-07:00

We have come to the conclusion of an amazing three weeks in the country of Croatia. Our time here has been filled with academics, culture, explorations, and new friendships. The blog will be complete on Sunday, so please check back then to read our last posts and see some other pictures. We have thoroughly enjoyed our time studying abroad and hope our blog has given you some insight in international health.
- Thanks for following our trip
- Ben, Elizabeth, and Rachel

Dubrovnik

2009-05-31T14:29:00.000-07:00

May 29
Friday morning we started the morning very early and loaded the bus on the way to Dubrovnik. Dubrovnik is a city situated along the coast about 3 hours away from Makarska and we had to go through Bosnia to get there. We were given a brief history of the city. Dubrovnik was founded by refugees, but has a much more interesting history than that. To maintain peace in their city, they paid off other countries to leave them alone. The city is noted for heavy promotion of freedom and liberty. Dubrovnik was more interested in trade than territorial conquest and is also noted for progressive ideas for systems of governance.

There was (and still is) a fountain in the middle of the walled portion of the city and anyone was allowed to come and get clean water. A statue also stands inside the city walls that has a very important role for those not of nobility or wealth. The statue is a man, but that is not the interesting part. On the bottom of the statue, on one side only, there is a line carved in the stone. This line looks like it is part of the statue, so it is very easy to miss. The significance of the line is that it was used for people to measure their bought goods. People who were members of the peasant class were often short-changed on their cloth purchases because they didn’t know how much a specific measurement was supposed to be. The line was etched in the statue to allow these peasant people to come and measure their purchased goods and contest with the seller that they were indeed short changed.

Dubrovnik was heavily attacked in the Homeland War like Vukovar. They were attacked from the sea and because the attacks were so intense, this is actually the place that put Croatia on the worldwide map. There was a public outcry about the city being destroyed because of the cease-fire from 1992-1995 in the rest of the country, but there were bombings still occurring in Dubrovnik. Many of the old historical buildings and relics of the town were destroyed. There was terror among the people because random bombings still occurred during this time and made it unsafe for the citizens.

Dubrovnik was one of the first cities to recognize the United States independence and supported the country in their efforts to promote freedom and liberty.

As far as public health goes, Dubrovnik was well ahead of others concerning infectious diseases. Dubrovnik initialized the first systematic quarantine in 1337 because of the plague. They were realizing how the disease was being spread from ships coming into the ports bringing in vermin and fleas and separated out potential exposures as well as complete cases of the plague. Quarantine is when people are kept separate from the general population that have been exposed to the infection until they present with symptoms. This was utilized at the sea ports. Isolation is separating out people who have specific diseases from the general population, such as the plague or lepers. The public health office looked at data from registries of ships in 1337 and realized that more people equaled more diseases. Caravans and travelers came through Dubrovnik and had to swear that they had not been in an area exposed to the plague for two months. The place where people were traveling from determined the length of their quarantine, lasting from days up until months for some areas. This initialization of quarantine stopped the plague from being endemic in the area. The model was utilized in other parts of Europe because of how effective it was at controlling the spread of disease. The program was based on real data and it still heavily utilized in times today, such as the recent scare of the H1N1 Flu.

During our time in Dubrovnik, we toured a small museum of the “Defenders of Dubrovnik” from the Homeland war and visited the City Hall to meet with a local city planner. The speaker talked to us about urban planning for the city of Dubrovnik. The designer of the city wanted everything in a block and this model was utilized in other parts of the world after Dubrovnik was designed. The designer for Washington D.C. visited Dubrovnik to see how a city could be put in grids on a sloping land. We also discussed Manhattan and Philadelphia’s city layout, and Dubrovnik had small roles in their implementation as well.

The rest of the time we were in Dubrovnik we had free time to explore. Many students walked the outside city walls and saw how the city was during ancient times, as well as how life is there today. The city wall provided the students with amazing landscape photos.
-Rachel

Biokovo

2009-05-31T14:27:00.000-07:00

On Thursday, we visited the Biokovo Nature Park in Makarska. We started with a presentation by Ivana Gabric at one of the education centers in the park. In 1981 the park was designated as one of the 11 nature parks in Croatia, and in 1998 it was designated as a public institution. At the park, visitors can sightsee, hike, go on tours, and explore the caves. The park’s mission is to protect and safeguard nature, ensure undisturbed natural processes, and maintain sustainable use of natural resources. The financing comes from the national, county, and municipality budget; entrance fees; revenue from reimbursement; donations; and grant funding for projects. The park has 12 employees: the director, conservation manager, park rangers, technical and expert services, and a governing board with 5 members.

The park is located in part of the Dinaric Alps, covering about 19,550 hectares (48,309 acres), with heights ranging from 200-1762 meters (656-5780 feet). The highest peak at Biokovo is St. Jure. The park has a variety of wild plant and animal species, including rare and protected species. There are 120 cave organisms, 221 species of butterflies, 7 protected amphibian species, 21 protected reptile species, 13 endangered bat species, and more. Also located in the park is the Biokovo Botanical Garden Kotisina (16.5 hectares, or about 40 acres).

The park is a very valuable resource to the surrounding community. In the park, visitors can see the traditional architecture, pastoral housings, Illyrian heaps (tombs), churches and chapels, and traditional agriculture and farming techniques. The park offers educational programs, ecological workshops, presentations, discussions, and informational centers. The park also encourages stewardship in the community. People can come to the park to learn about nature and their environment, and what they can do to help protect it. Biokovo is also important to the Makarskan community identity. Having this resource available to the area helps strengthen the community and provides many opportunities to improve overall health through many facets.

The Biokovo Park also supports social bonding. Many school groups, tour groups, and families come to the park. It is a great opportunity to get out and get physical activity. Coming to the park to hike or ride bikes can help many chronic diseases, like cardiovascular disease, high blood pressure, and osteoporosis. There are many marked trails throughout the park so that people can hike on their own. We saw several people hiking and riding bicycles throughout the park. Our group took vans part of the way up and hiked to one peak. We hiked back down and had lunch, then took vans to St. Jure, the second highest peak in Croatia.

The park is a great place for individuals to come to relieve stress through exercise and meditation. The park can also serve as a place for people to improve their spiritual health. Visiting the park can help improve mental health problems such as depression, anxiety, self-esteem, and phobias.

Many residents of Makarska and the surrounding areas have farms in the mountains. They typically grow potatoes and other vegetables, and many of them have cattle and horses in the park. These farmers have improved health from farming, clearing the fields of rocks, herding their cattle or other livestock, and hiking to their farms.

The weather was perfect for our hike, and the storm from the night before gave us a clear view of the islands off the coast of Makarska. The view from the peaks is absolutely amazing. One of our professors, Dr. Tir, pointed out all of the familiar parts of Makarska, like the street our apartments are on. We had a great time hiking and visiting the Biokovo Park and recommend this to anyone who is in Makarska.

- Elizabeth

Bosnia

2009-05-31T14:26:00.000-07:00

Stepping off the bus in Mostar, Bosnia, there was a clear difference between the previous stops along our journey in Croatia. From the masses of dilapidated buildings to the trash cluttering the city streets to the many gypsy beggars, it appears to me that the wounds from the Homeland War are not as well healed as in most of Croatia. In most cities we have visited in Croatia, the memories and pain of the war are still vivid, but much of the external damage has long been repaired, yet for some reason there is a sad, sobering feeling that comes over as you walk the streets of Mostar. While in the U.S. I am accustomed to the sight of beggars; seeing the gypsy mothers holding young children and begging for money was far more difficult to see in Mostar.

Visiting the University of Mostar, we learned a little bit more about the current political atmosphere in Bosnia and about the University itself. Bosnia is a very complicated country, being comprised of three main ethnic groups: Muslims, Serbians, and Croatians. Bosnia was home to some of the most brutal atrocities committed during the homeland war of the 1990’s. While all groups were involved, most of the acts were committed by the Bosnian Serbs to the Muslims. Even though the fighting has ceased for a number of years now, a very complicated political structure remains in Bosnia. The three main ethnic groups each alternate the presidency and it is very difficult to get anything accomplished with the current political system. While it does not seem to be very high on the list of priorities for such a war-torn nation, the political structure makes the health care system very complicated for the people of Bosnia. Health care is governed by the different cantons in Bosnia, or city-like structures with no real national health care plan. The lecture was not focused on health care in Bosnia, but it seems reasonable to assume that heath care governed at the city level leaves the Bosnian people with differing quality of and access to health care. Talking with some students at the University of Mostar, it seems that this structure only allows you to access health care services in your canton of residence. Thus if you were in another part of Bosnia and needed medical services, the health care plan would not pay for these services. I can only imagine that this system would leave the more urban cantons with better access and quality health care services than other rural cantons.

From the lecture, we learned that due to political disagreements there has not been a census in Bosnia since 1991, long before the end of the war. With no census data in nearly 20 years, it would be very difficult to have any accurate health statistics at a population level. If the political system is so dysfunctional that it cannot even agree on a census, I have little faith that good epidemiological work is going on at the government level in Bosnia.

In addition we learned from our lecture prior to arriving in Bosnia that human trafficking is a growing problem for Bosnia. In fact, in 1995, 25% of women working in night clubs were trafficked, and there are approximately 2,500 trafficked women working in brothels within Bosnia. These numbers are shocking because Bosnia is a relatively small country and because of the extremely cruel nature of trafficking. Many of the young women from poorer countries are tricked into this trade with promises of a better life, offers to be a nanny for a rich family and to learn trades to make a future for themselves. In reality they are often smuggled across country lines and forced to work in the sex trade, factories, and generally treated as less than human. A country such as Bosnia, ripe with political struggles, is a likely place for trafficking to occur. With no truly effective government to provide true oversight, corruption can run rampant and often times police play key roles in allowing trafficking to occur. For example the police may be paid to keep quite or paid to alert offenders of raids, or may even be night club owners and directly involved with trafficking of women.

While I have only seen one city in Bosnia, my first impression of this country based on our visit to Mostar is mixed. Bosnia seems to have a great deal of work ahead if they are to truly recover from the Homeland war and to perhaps one day reach their goal of getting into the European Union. With such a defunct government, the people of Bosnia are left with little in the way of leadership and are struggling because of this. While some problems obviously exist because of the political problems, we don’t even know the full extent of the public health situation in Bosnia and thus little can be done to improve it. Yet with all the sadness, I also witnessed great enthusiasm and hope from several young people from the University of Mostar. I can see that this younger generation has grown tired to the status quo and is ready to bring about change and produce a brighter future for the people of Bosnia. While it seems recovery has been slow, I remind myself that Bosnia is less than 10 years removed from a brutal war that many in the U.S. can likely not even imagine and full recovery may take many years Hopefully the Obama administration will make a substantial effort to help the people of Bosnia finally recover and lead the lives they truly deserve.
-Ben

Split

2009-05-31T14:24:00.000-07:00

Today we visited Split, a city with a rich Roman history including its most famous attraction, Diocletian’s palace. Diocletian was an emperor of the Roman Empire and upon being one of the only emperors in history to step down from office, he built his palace which remains today in Split. Being my first time traveling to Europe, I am amazed by how many historic structures remain, and by how well preserved they are. Along with our previous stops in Istria, including the amphitheater in Pula, Split reminds me of the significant influence that Romans had in many areas of Croatia. This is significant to public health because the Romans were innovators in many areas of public health, realizing the link between exposure and resulting disease. This is an example of how early public health efforts were conducted, using trial and error and simple observations. These observations lead the Romans to develop aqueducts for providing clean water, sewer systems to remove contact with waste and to create public baths for cleanliness. Ancient Romans believed that the main goals of life were health, beauty, and happiness, and baths became a central part of the Roman life. These baths, many of them public, were places for more than just bathing. They often included attached gymnasiums and were central social meeting spots. These baths were precursors to the health and wellness spas that are found throughout Europe today.

Some of these innovations can be seen today inside Diocletian’s palace, including in the basement where remains of the plumbing infrastructure are on display. The ancient Romans used aqueducts to pull water into the city, not using the common lead pipes of the day, because they realized from trial and error that lead made them sick. Walking through the basement of Diocletian’s palace, I couldn’t help but wonder if .there may be health implications from breathing the air. While an interesting sight, there was a lot of moisture and mold growing on many of the walls. I tried to discover if regular air quality checks were conducted to see if it was safe for the many tourist, while unable to find an exact answer I have doubts. This mold combined with possible radon from the stone and rocks of the basement could have significant respiratory health implications if at high enough levels.

After an afternoon of touring the palace and surrounding areas, we finished the day in Split with a visit to the former home and museum of renowned artist Ivan Mestrovic. One of the best known artists in the region, the works of Mestrovic can be seen throughout Croatia, including the statue of Nikola Tesla in downtown Zagreb. Nikola Tesla is an important Croatian figure and is known as the discoverer of AC electrical current and radio waves.
-Ben

Health in Makarska

2009-05-28T07:49:00.000-07:00

On Monday, May 25th, all of the students went to the city hall in Makarska to meet with the director of the legal department. She talked to us about the city’s development plan, tourism, and traditions. The government of Makarska is trying to encourage tourism and development of the area, while still maintaining the natural beauty of the city. To help maintain the water quality of the Adriatic Sea, Makarska has recently built a water treatment facility that treats all water before being released into the sea.

After our talk with the director of the legal department, we spoke with Mr. Josip Paunović, who works in the city manager’s office. Mr. Paunović covered a lot of health topics, including smoking, alcohol, substance abuse, and access to health care.

The government implemented the recent smoking ban to help reduce the health care costs related to smoking. The law initially started out as prohibiting smoking in workplaces, but instead of introducing new limitations gradually, the ban was extended to include all indoor public places. To enforce this law, there are inspections in bars and restaurants, and the fines can be at all levels: the individual that is smoking ($200, or a fifth of the average monthly salary), the server allowing the customer to smoke ($2500), or the bar/restaurant owner can all be fined ($20,000).

The smoking ban in Croatia is a very important first step to reducing the number of deaths from smoking and secondhand smoke, but more actions need to be taken. There needs to be a government-funded program to help Croatians stop smoking, whether it be counseling, behavioral therapy, or subsidies to purchase nicotine patches or gum.

About a year ago, DUI laws in Croatia were set to zero tolerance, but the legal limit was changed to a blood alcohol level of 0.05 after complaints from restaurant owners that the law had affected their business. DUIs do not go on a person’s record, but the driver does have to pay a fine. The most commonly abused drug in Croatia is marijuana.

Tourism has many impacts on Makarska. During the year, there are around 15,000 people in the city. In the summer, this number more than doubles to 35,000 due to the large amounts of tourists that come to Makarska. During the summer, there are lifeguards and beach patrol along the busy beaches.

Littering is another problem, especially at the beach. There are people from many different countries visiting the beaches of Makarska, bringing their own customs with them. Some people do not think it is necessary to throw away their trash, while others clean up after themselves. To help with the litter, crews are hired to clean the beaches every morning.

The main problem that comes with tourism is injuries. The ER in Makarska sees about 150 patients daily during the summer, but there is no actual hospital in the city. Any serious cases have to be taken to Split for more advanced care. This can be a problem due to the 2 hour drive from Makarska to Split, and the type of transportation. The ambulances are not actually ambulances, but more like a pick-up van that is not equipped with everything that could possibly needed in an emergency. There are 5 medic teams in the city, and 4 ambulances. The number of tourists in the city during the summer can strain these emergency medical services. Since severe cases from Makarska are sent to Split, this can strain the hospital system in Split. The health center in Makarska was actually designed as a hospital, but because of political reasons, the city has not yet been successful in converting this facility into a full-service hospital.

Following our meeting with Mr. Paunović, the Public Health students went to a local health center and met with the Director of School Health. School health is under the Public Health Department in Croatia. The school system in Makarska has 3,700 students, with less enrolling each year.

A child’s first visit with a school health doctor is usually around May during school enrollment. In the first meeting, the child’s school health record is compiled, consisting of prenatal and maternal health, family history, immunization records, vision, weight, height, etc. A team made up of a psychologist, pediatrician, school health doctor, and the child’s teacher meet to discuss the child’s health record and determine if the child would be best suited for a regular school program or a special education program. The child and his/her family can take the school medical record to their primary care physician and/or keep it with the school health doctor. Comprehensive health exams are conducted in grades 1, 5, 8, and 9. In 3rd grade, vision exams are conducted, and in 6th grade, the student’s motor skills are evaluated.

The school health department provides educational programs on prevention, injuries, hygiene, epidemics, and tourism and prevention programs that encourage early detection through breast self exam or mammograms.

Unlike in the U.S., obesity is not a major health problem in Croatia. The prevalence of overweight and obese students has increased, but only 6% of all children have weight problems, while about 12% of 8th grade students have a problem with their weight.

To help reduce the number of young people that smoke cigarettes, the school health department has anti-smoking programs, lectures, and school classes. As for sexual education in schools, there is no official program. There are two programs that are being debated: a more conservative program teaching abstinence only, and a program that would educate on abstinence and safe sex.

Teen pregnancy is not as big of a problem in Makarska as it is in the U.S. There are only three teen pregnancies per 1,000 population in Makarska. The director of school health informed us that many students that get pregnant during school end up completing their high school education.

Regarding nutrition, the schools serve a snack between the start of the school day and lunch, and then lunch in the afternoon. Some schools have extended programs that also serve breakfast. There are many unhealthy snack and drink machines around the schools. A recent pilot program to introduce healthier snacks was not successful.

- Elizabeth

Tučepi

2009-05-28T07:46:00.000-07:00

Sunday May 23

We started the day with breakfast at our host restaurant and got ready to go hiking. We were hiking Tučepi- which is part of the mountain we have behind our apartments, but on a different side. We were told that the hike was going to be steep- but we didn’t plan on it being as steep as it was. We walked mostly on the road, and yes there were cars driving up the mountain, but sometimes we had to venture off the regular road and get in the brush. We braved the heat and the steepness of the mountain and made it to the wall of the mountain- pretty much the tree line.

When we stopped we also visited a Catholic church as well as a small museum depicting Croatian life many years ago. After the museum tour, we were offered some wonderful Croatian snacks. We had dried figs, fried dough, bread with olive oil, and cake. Drink choices were different forms of rakija made from figs or carob or a desert wine. There was an entire table set with food, but when we left, there were just a handful of figs left- everything else was gone!

Our tour guide then took us on another hike, but this time the trail was so narrow you could only put one foot down and walk heel to toe. We saw many homes, even our tour guide’s birthplace. We also were able to see that the people living on the mountain had many options for growing there own food. During the first hike of the day, we saw almond and walnut trees, pomegranates, figs, and a variety of herbs. The second part of the tour we saw artichokes, various fruits, and grapes. Getting up and down the mountain can be very tedious, so the inhabitants have to grow a lot of their food. While having snacks, we also were allowed to see a lamb being roasted. These people are able to sustain themselves very well for living in such remote places. We later had lunch at a restaurant on top of the hill and then made our way back down the mountain by vans.
-Rachel

Makarska Beach

2009-05-27T11:51:00.000-07:00

Saturday May 23

We had a tour of the city of Makarska given by one of our faculty members, Dr. Tir. We walked around from our host restaurant to the beach and then into the downtown area. Makarska is very different from any of the other cites we have been to. There is a café’ culture here, but there is not as many as in Zagreb. Everything in Croatia is done at a slow, laid back pace, very different from life in the U.S. There are lots of “tourists” shops lining the outside area of the beach and many different shops and restaurants away from the beach area.

The beach is completely different than beaches back home. There is NO sand- only millions of pebbles and rocks lining the shore and going into the water. The pebbles are smooth from years of been tossed around in the Adriatic. The actual “beach” area is much narrower than those back in the states. We have noticed that the beaches are relatively spotless for so many people to be on them on a daily basis. We were told that people are hired to clean the beaches and remove the trash, especially during high traffic seasons. The water is clear with hints of sea green and blues. The water is a lot colder than what we are used to in the U.S. too. On our tour we were informed of the possibility of stepping on a sea urchin while in the water. Stepping on one can be very painful and the spikes must be pulled out very carefully. There are no warning signs noting the possibility of this danger, nor is there a warning about slipping on the rocks. Makarska sees tourists from all over Europe and the world, so we feel like there should be some kind of warning sign letting people know about the potential dangers of the rocks- such as slipping or cutting one’s foot on a jagged edge of a rock, as well as sea urchin warnings.

The beach has been very family friendly. We have seen many children with school groups and many families in general enjoying the coast. There are paddle boats with slides that can be rented for an hour at a time, as well as many shops selling floats. There is also a large slide located on one side of the beach. Cafés and restaurants line the outside of the beach strip. At any time of the day, people can be found sitting outside having coffee.

We enjoyed spending our first day on the Dalmatian coast. - Rachel

Croatian ER

2009-05-25T07:34:00.000-07:00

How would you like to go to the emergency room for treatment and never have to pay for it? That is how the system works in Croatia. Everything is free- even the medicines. The “emergency rooms” here are more like our Urgent Care centers in the United States, but with more on-going services. The ER does not deal with major trauma issues, births, or major surgeries. These types of services are done at the hospital.

May 21st the Public Health Students visited a Croatian Emergency Care Center in Labin. We were given a tour by the Director of the Emergency Care Center, who is a medical doctor for 8 hours of the day and the manager of the center for 4 hours. We toured many of the different areas of the clinic, from the Emergency Receiving to other specialized areas of the clinic. The ER was built in the 1970s, and was once a full hospital. It is now basic emergency care and other services. Our guide noted that one entire building is empty and there is too much room now, and they have to pay a lot of money to pay for the unused building. There are about 25,000 people in the area and the center sees about 40 patients on a normal day, and up to hundreds on the weekends. The majority of the patient load in the summer comes from tourists. It should be noted however, that the free services are only free for the citizens, not tourists. Tourists have to pay for treatment and medicines.

The ER provides Basic Life Support, Emergency Life Support, x-rays, basic surgery (2 rooms), EKGs, and general care for everyday occurrences (sore throats, headaches, etc.). Other services offered by this Croatian ER were dialysis, hospice, a dental clinic and dental moldings, school health, immunizations, laboratory for blood work, pharmacy, rooms for Hepatitis A and B, and radiology and diagnostics. Dialysis patients come 3 times a week and there are about 22 patients who come. We visited the Dialysis room and saw about 6 patients receiving treatment. The hospice in Croatia differs from the U.S. that when elderly people have been in the hospital and need to monitored in a clinical setting and there is no room for them to be kept in the actual hospital, are moved to the ER center.

There is an on-site dentist and dental lab where false teeth are made due to the aging population near the ER. We also were allowed to go in this room and saw all kinds of teeth impressions, dentures, and workers molding the fittings with flames and paste.

We also visited the school health areas. Children come to this area for immunizations and education. Croatia also takes the vaccines to the children at school. The schools are visited almost everyday. The student’s health records are also kept at the ER center, not just at the school. The guide noted that sex education is presented in regards to STIs and safe sex, but she noted that they do not give out condoms because of the large Catholic influence in the area. Students can come to the clinic and have more sexual health education if they want it. The clinic does offer the Gardasil (quadrivalent-HPV vaccine) shot to females for $1027 kuna, which is roughly $192 per shot.

The ER gets lab work the same day, sometimes in 30 minutes depending on the type of labs requested. The patient’s general doctors will receive the results the next day. Wait times for being seen depend on how many other people are waiting for treatment, and if the doctor is out on an ambulance call. Sometimes the wait time is 30 minutes, and others it is 2-3 hours. There is no triage system, so it just depends on what kinds of symptoms a person is experiencing to determine the order in which they will be seen. Chest pain or asthma attacks will be seen immediately, and those patients who are there for mild illnesses and discomforts will have to wait to be seen a little longer.

The Director noted that the doctors are paid based on how many patients they see and the doctors depend on large amounts of patients, because this is how they pay for other employees such as the Speech Therapist, Psychologist, Accountants, Administrative Assistants, and Cleaning services. This kind of works in their favor since many people come into the clinic for mild illnesses and complaints, but also if the patients General Practitioner is working, the patient is sent there and the ER will not treat them.

We saw inside of the ambulances that are used for bringing people to the clinic and they are very different from ambulances in the United States. The vans are not fully stocked at all times, because it costs too much money to keep them fully stocked. When there is an emergency call, the EMTs pick up a case filled with medical supplies and put it on the van. When we first entered the ER, we got to see some of the EMTs bringing in someone from heat exhaustion.

Other services our guide mentioned were that the Red Cross offered CPR training and diabetes education. Doctors from the hospital were sometimes asked to do presentations at alcoholics meetings. There are other education efforts in the works, but for now will have to wait because of money concerns.

Our time at the ER was very informative. We learned a lot about Croatian medical care and saw a different side of Public Health than we have seen on the other parts of the trip. - Rachel

Drive to Makarska

2009-05-23T13:29:00.001-07:00

This morning we departed bright and early from our hotel atop a mountain in Istria and are heading for the coastal region of Makarska. While we are spending over eight hours on the bus today, I have sighted a few things worth mentioning. The regions of Croatia we are traveling through today are located along the cost of the Adriatic Sea and thus strong winds are a daily occurrence. These types of coastal winds provide great opportunities for resources but also offer some challenges for public health. While most days man and wind can interact with no problems, this is unfortunately not always the case. In the winter months especially the tidal winds can be especially strong and have been known to even cause traveling cars to turn over during a strong gust. Obviously this is a very serious traffic safety problem yet some safeguards have been put in place to protect drivers along this region. In many of the stretches of highway most exposed to the tidal winds, special wind barriers have been placed to help prevent serious accidents due to these strong gusts.

While the wind can pose some challenges, it is also a great resource for energy and it seems that many areas of Croatia along the coast are harnessing its potential. Traveling along the highway, I have noticed several mountain tops lined along both sides with turbines for harnessing the power of the wind. It is not every day in the U.S. that I come across so many windmills in one place. It is unfortunate that many coastal areas in the U.S. are lined by high price homes and residents will often protest proposed wind turbines because they don’t wish to have such a ghastly sight near their property. I find that these windmills almost add something to an already beautiful coastal landscape in Croatia. While they are noticeable atop the mountains, they have a certain serene nature and I believe add character to the landscape. Beyond aesthetics, these wind turbines can help to improve air quality and thus human health. If you have watched t.v. over the past year, you’ve probably seen commercials featuring the well known oil tycoon Boone Pickens. Over the past several years, Mr. Pickens has become a strong advocate for energy independence, or reducing our dependence on foreign sources of oil. While many of these commercials focus on increasing the use of natural gas, which is abundant in the U.S., Mr. Pickens is also an advocate for wind energy. In fact, he is currently planning the construction of the largest “wind farm” or collection of wind turbines in the U.S. which will be located in the state of Texas.

The energy power of the wind is significant and its production has virtually no negative impact on the environment. Yet, wind power alone will never be enough to provide all the world’s power. A sound energy policy will utilize all possible environmentally friendly sources of energy: wind, solar, geothermal, and even perhaps nuclear to reduce the amount of energy from fossil fuel burning facilities. Currently the most common method of energy production is coal burning, which emits large amounts of so called greenhouse gases such as carbon dioxide, nitrous and sulfur oxides, among others. Through various mechanisms, these greenhouse gases pollute the air and can cause increased mortality and increased rates of various respiratory disorders and some forms of cancer. Thus it is exciting to see these wind turbines lining the mountains. By placing even more along high wind regions, Croatia will further eat up the part of the energy pie occupied by fossil fuels. With this small step Croatia will help to ensure cleaner air and better health for the people.

-Ben

Pula and Health Communication

2009-05-23T13:18:00.000-07:00

The ancient ruins of the Coliseum in Rome are among the most recognizable landmarks on earth, but did you know that Croatia is home to an ancient amphitheater of its own? Our journey today took us into the city of Pula which is home to the 6th largest and 2nd best preserved Roman style amphitheater. Pula and the entire region of Istria have some very noticeable differences from the rest of Croatia, especially the regions we have seen around Zagreb. This is because Istria is heavily influenced by Italy and has at various times been under Italian rule and the rule of others as well. While this makes for cultural and architectural differences such as Italian influenced cuisine, does this impact public health in any way? Following our lecture at the University of Pula with David Mandic, I would have to say that it does. Professor Mandic spoke about the unique aspects of language in Istria, a region where several different dialects are spoken. While there are some similarities among the different dialects, there are also great differences which can make communication among the various people of Istria difficult at times. This can impact public health by making health communication a very challenging task. Can you imagine being in charge of a public health campaign and having to reach people of multiple dialects within a single city? This seems like a big challenge and one that could leave those in the minority dialects with lack of access to important health information. This unique language situation of Istria could also cause problems for individuals trying to communicate with their health care providers, who may not speak or understand the given dialect. While I am not sure how much of a problem this is for public health workers in Istria, it seems like something that would certainly need consideration before undertaking any type of public health endeavors.

-Ben

Roč and Hum

2009-05-23T13:10:00.000-07:00

May 19- Our charter bus took us to the border where Croatia and Slovenia are having disputes over a bay that touches both countries. We heard from two speakers while at the bay about how long it had been going on, what was the current status and what could potentially happen. Members of the E.U. virtually share all borders, there is no “line” to state when you are entering one country or leaving another. Slovenia is delaying Croatia's acceptance into the E.U. by not providing a unanimous vote for Croatia to join the E.U. This dispute will be resolved in Croatia gains acceptance into the European Union.

After our visit to the bay, we met up with a familiar face, Dr. Alexandria , to visit the cities of Roc’ and Hum. These towns were both very old and situated high atop a mountain. In the city of Roc’ we saw children having class at an elementary school, a small church, and the beginning of the Glagolitic trail leading to Hum. The Glagolitic language is one that has a rich history that was almost forgotten, but a few people decided to restore it to Croatia and its heritage. We stopped at four Glagolitic symbols along the road to Hum. These visuals were put up in the 1970ties so that the Glagolitic language would not be forgotten and would be remembered as an important part of Croatian history. We saw a table with three legs to represent the Trinity; a block statute, stone seats and a chair to represent learning in nature, and the Glagolitic letter “S”. We then stayed on the bus to view the other seven symbols. All of the symbols were made of stone. The final symbol led us into the city of Hum. Hum was recognized as a city a long time ago by a King, and still maintains being a city, even though there are only twenty people living in the city. Our guide told us that it Hum has everything a regular city has, but just a handful of people. The view from Hum was really pretty. It was really interesting to see how these cities were still in existence, since they were so remote and so tiny.

After our tours here, we were on out way back to the top of the mountain to Hotel Kastel.

- Rachel

Rural Health and Zumberak

2009-05-23T12:57:00.000-07:00

Rural Health and Zumberak

Traveling up the narrow roads to the village of Mrzlo Polje, it feels as if you are traveling back to a far simpler place and time. The quiet life of this sparsely populated mountain village in the Zumberak region of Croatia is a far cry from the hustle and bustle of the vibrant city of Zagreb. You will not find a single must see statue or remains of any castle like other mountain regions of Croatia and yet there is still something so pure and captivating about Mrzlo Polje.

Traveling through Mrzlo Polje the term rural health takes on a new meaning. When I think of rural health several smaller Georgia towns come to mind, but these pale in comparison to many villages in the Zumberak region. Mrzlo Polje currently has a population of 48 people with the average age being 58 years. Beyond merely being a very small village, perhaps more importantly to public health, Mrzlo Polje is an incredibly isolated village. Upon touring this village, it becomes clear that there are no gas stations, restaurants, grocery stores, doctors’ offices, hospitals, pharmacies, or any other store within eye shot from any part of the mountain. In fact, the nearest doctor is located in a bigger town approximately 30 minutes away. Ok, so 30 minutes is not that far away but traveling these steep and narrow mountain roads it feels like death is lurking around each twist and turn. While successfully navigating these roads in the beauty of late spring seems like a small miracle, during the heart winter it hardly seems possible. This all means that Mrzlo Polje has incredible limited access to health care, which can present significant implications for the health of populations. To complicate the public health picture even further, only one citizen has a college education and many of the rest have very limited formal education. This makes it a necessity for any public health efforts to be thoroughly planed with educational levels in constant consideration. From the perspective of the Social Cognitive Theory and determents of health, Mrzlo Polje seems like a public health nightmare. The lack of education, priority, money, and certainly access are all working together and likely resulting in negative health implications for the local population.

While the Zumberak region and Mrzlo Polje in particular may not be the typical city, they are useful case study and provide examples of the special health needs and characteristics of rural communities throughout the world. Rural health is an important public health focus in Croatia where a great deal of the land is considered rural. Ensuring the health of rural populations is not just important for the individuals in these communities, it is important for the health system of Croatia or any country with rural populations. This is because currently we know that rural areas are more likely to have long term chronic conditions than urban areas and treating chronic conditions is a huge drain on any medical system. Furthermore, we know that access is the number one predictor of using screening services and thus rural populations get fewer cancer screening than more urban populations. Between the lack of access and aging demographics of Mrzlo Polje and other rural communities in Croatia, the rates of chronic disease and associated medical costs are likely a growing burden. It seems that in a country with a social medicine system financed through the government such as Croatia, reducing health care costs would be a key concern. Yet it seems that these communities are often left out of the public health picture with little more than one visit from a physician every other week as the main health care infrastructure. There is no doubt that lack of access to health care resources is causing increased rates of chronic conditions among the vast rural populations and thus increasing health care costs.

One possible resource for Mrzlo Polje and other rural communities in the future is the possible satellite location for the University of Georgia in this region. The vision for this project would use the existing but no longer used school buildings for this community and turning them into a research and outreach center in the Balkan region. While this project is still in the developmental phase, it is envisioned that researchers in fields such as public health, agriculture, veterinary medicine among others could conduct research in their fields while also providing information and resources to the local community. While this will be a very worth while project careful consideration should be given in order to not disrupt the unique character of this region. This partnership could perhaps bring more resources to the community and help to provide better access to health care in the Zumberak region. Beyond being a great picture stop, Mrzlo Polje has highlighted the significant work that needs to be done in public health to ensure that health care needs are being properly met in communities of all sizes and locations across the globe.

Ben

Special Education in Croatia

2009-05-22T12:46:00.000-07:00

Monday, May 18

Today the Public Health students went to the Centar za odgoj i obrazovanje Dubrava, a special education center in Zagreb. The center opened in 1966 and serves all of Croatia.
It is the only facility of its kind in the country, serving 158 teenage students with mild physical and mental disabilities. Students who live in Zagreb come daily to the school, while 80 of the students from other parts of Croatia live at the school.

One of the professors at the school gave us a presentation on the history of the school and all of the activities they do, and then took us around the school. The staff includes professors, specialists, special needs caregivers, physical therapists, nurses, and a doctor that visits the school once a week. The number of students is constantly increasing, and the school does its best with the limited resources available. The school received federal funding, so the students (even the residential ones) do not have to pay tuition. Volunteers from the community and students from the Special Education Department at a local university help out at the school on occasion. When the school has extra money in the budget, they add programs like animal therapy.

The facility is bright and colorful, with plants and artwork all over. Some of the programs include clock and watch making, mechanics, graphic design, knitting, shoe making, economics, and pre-law. The school has a nurses station, cafeteria, TV areas, gymnasium, physical therapy room, a swimming pool, dorms, and classrooms for each specialty. Two students from this school now work with the local Parliament, and three of the students are now at the Philosophical Department at a local university.

Despite the limited resources, the school has so many fun programs the students can get involved in. The students can also participate in music groups, choir, sports, team building activities, theatre, dancing, hiking, daily life activities training, and trips around Croatia and Europe. The students have participated in several international competitions, like the Special Olympics in Peking. The school also has a homecoming/prom event, and a school king and queen are chosen. The school always has a recognition ceremony at the end of the year and feels that it is very important to encourage and recognize achievement.

Being a school for students with physical disabilities, the entire facility is handicapped accessible. There is a ramp to the entrance of the building, and a ramp to the second level of the school. All of the doors are wide enough for a wheelchair to fit through, and have metal reinforcements on the lower part of the door. All of the doorjambs have a slight ramp so that wheelchairs can enter each room. The doors have horizontal handles instead of knobs to make it easier to enter a room while seated in a wheelchair.

Though the country is moving towards integrating special education programs into regular school classes, this facility serves a very important purpose. Without this school, many Croatians with mental and physical disabilities would not receive such a high quality education. This school is specially designed for them, with an individual focus for each person’s needs. Every student receives the tailored services they need, and without this school the entire country would suffer. Students from this school learn valuable skills that can help them throughout the rest of their life.

We had a really great time at the school and are very thankful to our tour guide and to Dr. Spolijar-Vrzina for accompanying us to the school.

Interesting fact: The school was used to house people that had to leave their homes during the Croatian war.

- Elizabeth

Zagorje

2009-05-22T12:34:00.000-07:00

Sunday May 17

Today we went to Zagorje to see the Veliki Tabor castle. The castle is in the process of being restored, and was opened just for our group. It was built in 15th century. We got to see rooms in the castle that are being excavated and renovated, and pieces of ceramics and tiles that have been found in the castle. After touring the castle, we went to Kumrovec, the town where Tito was born. The town has been preserved as it was when he lived there, with the homes and buildings open to tour.

Next, we had lunch at Gresna Gorica. The restaurant is set atop a hill, with peacocks and guineas walking around. The meals in Croatia are usually (at least) four course meals. The appetizers were typical Croatian foods, like olives, peppers, bread, prosciutto, cheeses, etc. One of the appetizers was something we’ve never seen: jellied meat. Only one of the people at our table was brave enough to try it, and she didn’t like it. Next, we had soup and salad, and then the main course included two meats: pork and fried chicken. We also had baked beans with our lunch, and ended the meal with two desserts: a cheesy pastry and an apple cinnamon pastry.
-Elizabeth

Smoking in Croatia

2009-05-22T12:27:00.000-07:00

For centuries, tobacco has been utilized by the human population for a variety of uses. The current most common use of tobacco is for smoking. Tobacco is related to 6 leading causes of death worldwide. Twenty-two percent of the world smokes. In regards to gender, 36% of men smoke, whereas only 8% of women engage in this activity. Smoking is typically more culture based than behavior based. Lee and Collins state in their text that “A broad decline in smoking prevalence across most high-income countries in recent decades has coincided with substantial increases among low- and middle-income countries”. Two-thirds of smokers worldwide live in Bangladesh, Brazil, China, Germany, India, Indonesia, Jordan, Turkey, the United States, and Russia; one-third of all the adults in Eastern Europe smoke.

Lee and Collins state that

Smoking causes 1 out of 10 deaths (WHO, 2003)

By 2030 low and middle income countries will account for 7 in 10 of all tobacco-related deaths

In China alone, 1 million people are expected to lose their lives this year from smoking. and this number will move to 2 million by 2025

In India, around 80 million males under the age of 35 will lose their life to tobacco (Thun and da Costa e Silva, 2003)

Smoking is extremely common among the people of Croatia. One of three people in Croatia smoke, with 40% of that being men and 30% being women. The ages range from pre-teens to the elderly. We have noticed many youth smoking in front of adults, either at cafés or just out in the town. There seems to be no objection from the adults to these underage teens (and pre-teens) having or using cigarettes. Since there is so much smoking taking place, our concern would be of second-hand smoke. There seems to be advertisements to discourage smoking and there are large warning labels put on the cigarette boxes that translate to “smoking kills” or the health affects of smoking (one box we found translated into "smoking damages sperm"), but we have yet to see anything about second-hand smoke being dangerous.

Kiosks (sidewalk newspaper stands with basic convenience supplies) and tobacco shops are abundant in the city of Zagreb. Every outside table at cafés and restaurants provide ash trays. The cities we have visited have all been very clean with no litter, except for that of cigarette butts.
Croatia has recently made legislative changes to ban indoor smoking. This is a positive change to benefit the health of Croatians, but the café culture in Croatia seems to promote social smoking.

The café street culture is very unique to Croatia. Every restaurant or bar has chairs and tables on the outside sidewalk (or in the middle of streets) with large umbrellas to provide really nice lounge areas. At any time of the day, there are many people seated in these areas. This is where the smoking takes place. It is hard to find a seat not near a smoker. Even though the smoking is outside, there is still a heavy exposure to the smoke since the area is very congested. Even gelato shops or coffee shops have sitting areas with high-top tables and chairs. Many of the smaller business establishments have a couple of standing areas on the sidewalks and it is almost impossible to not have to walk through a cloud of smoke.

We have also observed parents who are at an outdoor café smoking around their infant or toddler children. There seems to be no concern that second-hand smoke is dangerous.

Ben noted earlier that the air quality of Croatia is significantly different than that of the United States because of the use of “smart cars” and electric trams, but the smoke that fills the air makes it hard to breathe, just as vehicle pollutants would. - Rachel

Croatia Health Statistics

2009-05-22T12:24:00.000-07:00

As we traveled to Plitvice Lakes, the Public Health students were informed of the health statistics of Croatia by our teacher. Croatia has a population of 4 ½ million people, with about a 50/50 ratio of men to women. The life expectancy is 75 years for Croatians. Women generally live longer than the men with an average of 79 years, while men live to about 72. The GDP spent on healthcare is 7% and the average income is $14,000.
The leading causes of death in Croatia are cardiovascular disease and cancers. The #1 killer of Croatians is also the #1 killer of Americans. Stroke affects 1 out of 3 Croatians. The leading types of cancers in Croatia are tracheal, lung, and bronchial cancers. The large prevalence of smoking contributes to these cancers, but also the exposure to dust from working in industrial settings (which is the #1 source of employment in Croatia). Colon/Rectal cancers are the next leading causes of death for Croats. This can be attributed to sedentary lifestyles and the gluten-sensitivity that is a genetic trait of the Croatians. The next leading cause of death is cirrhosis of the liver. Croats consume considerably more alcohol than Americans. Cancers appear again on the list for the 3rd time with stomach and breast cancers contributing to deaths in Croatia. The list rounds out with injuries that are either self-inflicted, brought on from the war, or external poisonings and hypertension. Hypertension affects 55% of the Croatian population.
These top ten leading causes of death demonstrate that the country is in the process of becoming a more developed and industrialized nation, experiencing higher rates of chronic diseases more than infectious diseases. -Rachel

War in Croatia

2009-05-17T10:28:00.000-07:00

On May 14th, we visited Jasenovac in the eastern part of Croatia. During World War II, land outside of this town was used as the site of a concentration camp. It had natural borders provided by the rail system and the Sava river. Over 75,000 people died at this camp. During its first years, only men were sent to this "work camp," but in its last year, women and children were also sent here. The camp could only hold 3,ooo-4,000 prisoners at a time, so often times when new prisoners were brought to the camp, they would be executed immediately. Serbs, Jews, Roma, and people of other nationalities were brought to this camp.

The buildings from the concentration camp are no longer standing. Local residents disassembled the buildings to get bricks to rebuild their homes. Mounds of dirt and depressions in the earth mark where the buildings once stood. A museum has been built to educate visitors about the camp, and a memorial "Stone Flower" has been erected to honor those that died.

On May 15th, we headed to the city of Vukovar. This city was heavily shelled and bombed during the Croatian war in 1991. It was the first main target of the Yugoslav military, and was under seige for three months. According to the 1991 census, there were 44,639 inhabitants; after the war, in 2001, there were only 30,126. Approximately 15,000 residents of Vukovar sought refuge in their basements, with limted access to fresh water, safe food, an energy source for cooking or heat, and medical supplies. Many people came to the Vukovar Hospital for refuge during this time. However, this location was not a safe haven as it should have been. The hospital was also bombed, with some shells penetrating through six floors all the way to the basement where the patients stayed. At one point, the military forced 266 people from the hospital, and took them to a hangar for one day where they were tortured and beaten. The next day, they were taken to a field and executed, buried in a mass grave. We visited the hangar (that is now a museum), the site of the mass grave, and the memorial cemetery where the exhumed bodies have been buried.

Our tour guide in Vukovar lived there during the war and stayed in her basement for part of the three months. She spoke to us of what it was like, living in her basement, eating food rations of bread and beans, having no electricity, and very limited amounts of water for drinking and bathing. She discussed the health effects of war that some of the people have sufferred in Vukovar. There has been an increase in cancers among the residents, increased aggression (that the children then develop from being around their parents), and post-traumatic stress disorder (from depression to reliving the trauma).

In addition to war causing high numbers of casualties, war can have an extreme impact on the infrastructure and health system of a country. Human resources are devoted to the war, while health services must attempt to continue, despite the fact that medical and health professionals may not be able to become recertified during war. Access to health care and services is disrupted during war. Whether people cannot leave their homes to get them, or if they have been displaced and do not have health services, this can have a major affect on health. Vaccines need to be kept cold in order to be effective, and equipment and supplies may be in high demand. It may also be hard to get to these services because roads and the buildings where these services are provided can be destroyed. War can also make it unsafe to leave your home or place of refuge to seek health care. In rural areas, resources may relocate to more needed areas. Also, health data is typically not accurate during wartime because there is no way to measure health in a population at war.

Landmines are also a common problem that result from war. Many landmines are not activated during the actual war, causing problems for years to come. In some parts of Croatia, landmines have been deactivated, while in others, the fields have been marked off and signs instruct people not to enter. Landmines cause disability to the person that activates it, requiring more resources to treat this person. Landmines are commonly put in remote areas, so that whoever is affected by this (depends on the typical gender roles in the area) may not be near anyone else who could help them. Also, if there is a person near, they may not be willing to risk going into the field to help the person because there may be more landmines. About 75% of landmine victims die within 6 hours if they are not cared for promptly. Because landmines cause dirt to enter the wounds that are caused, infection is very likely, and can lead to blood vessel damage.
-Elizabeth

Osijek

2009-05-17T09:43:00.000-07:00

May 14th We visited the town of Osijek. Osijek is located in Eastern Croatia, near the Drava River. It is a town scarred by the war, but is slowly being rebuilt to its previous beauty. Here we noticed that there are huge differences in leisure and recreation than in Zagreb. The town is very family oriented and our guide said that it was a very safe city. We went on a walking tour and were able to see many oppurtunities for exercise throughout the town. Near the river there is a pedestrian and bike path. No cars are allowed on this level. Many people were riding bikes with children secured in seats on the back. The majority of the kids who were in the seats or on their bikes had on helmet. Near the pedestrian and bike path there were soccer fields, tennis courts, skating areas, playgrounds, and parks.

We saw people of all ages taking part in tennis lessons or games. Parents were playing with their children on the playgrounds, not just sitting and watching them from afar. Many younger girls were skating around not just in the parks, but on the sidewalks in the city as well. We also noticed rowing equipment near the river. There was a lot of green space in Osijek. The town seemed to appreciate lesiure and exercise more than the residents of Zagreb. Zagreb is more of an urban city than Osijek. We have only seen two workout centers on the outside of Zagreb. There are people riding bikes, but it is used for travel, not exercise. We do know that there are tennis courts near our hotel, but we have not visited them yet.

While we were there the town was having a street festival. Families were all around listening to music and enjoying food and carnival attractions. In Zagreb we passed by a concert one night (for a political campainging), but it was not targeted to families.

Upon intering the city, there were recycling bins for various materials. We have not seen this in Zagreb.

Osijek, though stircken by war, is a very lively and youthful town.

-Rachel

Public Health in Zagreb

2009-05-16T14:38:00.000-07:00

May 13th the Public Health students visited many schools and universities in Zagreb to learn about Public Health and Medical Schools in Zagreb. We visited the Academy of Science and Arts first to learn of Croatian Medical History, Andrija Stampar, and current issues in Croatia today. Public Health has many many roots in Croatia. X-rays, pharmecuticals, hygiene, prescriptions, sewage, and quarentine all have grassroot beginings here. For Croatia to be such a small country, they really have made important contributions to the field of medicine and Public Health.

Stampar, who was a man well ahead of his time, should be considered the Father of Health Education. His ideology and philosophy are all around preventative strategies and having the doctors come to the patients, rather than the patients having to search for healthcare. He held many notable positions during his time:

Graduated from Vienna Medical School
The Health Advisor of Croatian Commission for Social Welfare

Head of Department of Public Health

Founding member of Public Health School in Zagreb

Dean of the Medical School in Zagreb

Engaged in creation of the World Health Organization
Chairman of Hygiene/ Social Medicine

President of Yugoslav Academy of Sciences and Arts

Director of the School of Public Health

He was a reformer promoting public health and hygiene, while at the same time, had an input on international health. His view of Social Medicine consisted of 10 points:

Inform rather than conform laws

Understand the health problem (most importantly)

Improve health by working together

The physicial should be regarded as a social worker

Money should not be the issue in care; care of the patient should be the concern

There is no difference between rich and poor and having access to health care

The doctor should seek out the patient, not the other way around

Doctors should be the people's teacher

Health is of economic importance, not humanitarian- meaning that healthy people benefit a society more in terms of economics

Location of the doctor's activity should be in the community- people's homes, not in an office or lab

Stampar had a message that was clear and simple "health for all." This is where the name of our blog came from. We agree that health and healthy opportunities should be made available to all people, regardless of race, ethnicity, socioeconomic status, standing in the community, or location of the people. Stampar recieved much criticism from many people around the world, especially in the United States. He visited many notable schools from one side of the county to the other and was not highly favored. Stampar accessed many Medical schools around the world and stated "They learn how to examine a body in detail, why don't they learn how to study a community?" Here is where the foundations of health education were laid. Prevention strategies and health promotion take root in Stampar's teachings.

Stampar's teachings still have an impact on Croatia today. Students studying medicine in Croatia will all have a Public Health background upon graduation. Students spend 6 years in med school, 1 year in an internship, 1 year in residency, and potentially 3-5 years in specialty training. Students can enroll in med school after high school graduation with no undergraduate degree required. The first 2-3 years are pre-clinical classes and the last 3 are clinical classes.

The University of Zagreb provides many different disciplines for medical students. There is a post graduate program for those wanting their PhD and continuing education classes offered as well.

This is one example of Public Health going on while we were on one of the tours. It is a free blood pressure screening set up in the city square.

- Rachel

Plitvice Lakes National Park

2009-05-15T15:07:00.000-07:00

On Tuesday, we went to Plitvice Lakes National Park, located about 140 kilometers south of Zagreb. The park includes 16 lakes that change colors depending on what minerals and organisms are in the water. The lakes are linked by waterfalls and cascades, surrounded by lush vegetation, with 1400 different plant species and 55 different species of European orchids. The water rushing over the plants and rocks form travertine, a type of porous rock. Plitvice is also known as the site of the first victim of the civil war in former Yugoslavia that started in 1991.

While at the park, the Public Health students were to assess potential injury prevention strategies. Here are some brief observations to help you understand the dangerous aspects of this park:

There are handrails and guardrails on the most dangerous parts, but it would be helpful to have more throughout the trails and along the cliffs.

The trails can be rough - usually dirt or gravel trails that can have sharp rocks and tree roots sticking out of the ground.

There are no warning signs to alert visitors to the start of the steps on the walkway, how the wooden footbridge can become slippery from the splashes of the waterfalls, or of the steep cliffs.

Nearly half of the park visitors (1 million) come during June and July, which could be dangerous with such large crowds.

There is only one ambulance.

The nearest hospital is 40 km away. If there were a very serious injury that needed prompt medical attention, this distance may be too far.

During our visit, we were able to see firsthand how important safety is at the park. In a group just ahead of ours, a woman slipped on the wooden footbridge that winds around the lakes. She hit her head on the bridge, and was carried back to the dirt trail's end to be treated before being carried up the trail on a gurney. Seeing an accident like that makes everyone aware of how important it is to be attentive and watch your step.

To prevent injuries at the Plitvice Lakes National Park, we feel that there are two simple and feasible strategies that could be pursued. First, warning signs could be posted to alert visitors to the start of the steps on the footbridge, the steep cliffs, and how the bridges can become slippery when wet. Another idea is to add more handrails. Even having rope lining the trails could be helpful for park visitors.

Also, the park is not the most handicapped accessible facility due to the characteristics and layout of the park. Given that it is a natural setting, there is not much that can be done to make it more accessible. Some of the hills would be too steep for anyone with a physical disability, and after the dirt trails end, the wooden bridge starts and has steps that would not be accessible in a wheelchair. While we expected no one in a wheelchair would be able to maneuver much of the terrain past the park entrance and the first views of the lake, there was one visitor in a motorized wheelchair that was able to go all the way to the lower part of the trails at lake level.

- Elizabeth

Environmental Health

2009-05-15T13:12:00.000-07:00

While the layout adds to the character of Zagreb and makes for a very beautiful and functional capital city, it also has some very positive implications for the environment and thus the health of the people of the city. While there are still plenty of cars traveling down the city streets, the number pale in comparison to most big cities in the U.S. and one can spot far more SMART cars than S.U.V.’s parked along the side streets. Virtually all of the cars in Zagreb are very compact and surely more eco friendly than even compact cars in the U.S. This reduction in numbers of cars and their eco friendly nature surely help to reduce the amounts of carbon dioxide and other greenhouse gases emitted into the city air. In addition, the main transportation choice for navigating the streets of Zagreb is an electric tram system, or series or passenger rail cars that are powered via electricity. The city of Zagreb also lends itself quite nicely to walking and many locals and tourists alike reach their destinations on foot, the ultimate eco friendly transportation.

It doesn’t take any sophisticated equipment to detect the reduced levels combustion pollutants in the air of this city. In fact, one only needs to take a deep breath to realize that there is something very different from the air quality of most busy U.S. cities. As a student of public health, I immediately begin to think of how wonderful this is for the health of the people of Zagreb; decreased rates of asthma, lung cancer, other respiratory diseases oh my! But alas I quickly realize that around each new corner the noxious odor of cigarette smoke is penetrating my lungs, and my public health bubble has been burst.
- Ben

First Day in Croatia

2009-05-15T13:05:00.000-07:00

From first glimpse the city of Zagreb has some unique differences from most metropolitan cities in the U.S. Stepping off the train I felt surrounded by the history and rich culture that makes Zagreb a wonderful place to discover and explore. While the centuries old buildings are each a unique treasure in their own right, it was the stark differences in the layout of Zagreb that struck me as being most different. It was a culture shock to not see the downtown streets cluttered with SUV’s, waiting in droves at each traffic light for their chance to go. Instead, the streets of Zagreb are filled with Croats and tourists alike walking, biking, and perhaps most different to me riding the tram. Most of the roads in Zagreb were not constructed solely for the use of cars but instead are equipped with a system of rails with different electric trams zipping by every few seconds.